MEDICARE PRIVATE CONTRACT 

(In compliance with 42 U.S.C. §1395a; 42 C.F.R. § 405, subpart D) 

This contract is entered into by and between ___________________________________
(hereinafter called “physician assistant”), whose principal medical office is located at 696 Ritchie Highway, Suite 200, Severna Park, MD 21146 and___________________________________(hereinafter called “beneficiary”), who resides at ___________________________________, and shall become effective on this ___ day of ____________, 20_____, and shall expire on the _____ day of ____________, 20_____ (the “opt out period”), unless otherwise renewed in accordance with the 42 U.S.C. 1395a; 42 C.F.R. 405, Subpart D. 

PROVIDER OBLIGATIONS 

The physician assistant acknowledges that [he or she] [is or is not] excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act. 

The physician assistant acknowledges that this contract shall not be entered into with the beneficiary, or the beneficiary’s legal representative, during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. 

The physician assistant acknowledges that [he or she] must retain this contract (with original signatures of both parties to this contract) for the duration of the opt-out period, and that it shall be made available to the Centers for Medicare & Medicaid Services (CMS) upon request. 

The physician assistant shall provide a copy of this contract to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract. 

The physician assistant acknowledges that [he or she] must enter into a contract for each opt-out period. 

BENEFICIARY OBLIGATIONS 

The beneficiary, or his or her legal representative, accepts full responsibility for payment of the physician assistant’s charge for all services furnished by the physician assistant. 

The beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the physician assistant that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. 

The beneficiary, or his or her legal representative, understands that Medicare limits do not apply to what the physician assistant may charge for items or services furnished by the physician assistant. 

The beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the physician assistant to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. 

The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract. 

The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare and for whom payment would be made by Medicare for their covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out. 

The beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. 

The beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the physician assistant during a time when the beneficiary requires emergency care services or urgent care services, except that the physician assistant may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. 

The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract. 

[Optional provision, not required by Medicare to be included in the affidavit]: I understand that during the opt-out period, a Medicare Advantage plan may not by law make any payments to the physician assistant for any Medicare items and services furnished to the beneficiary under this contract. 

(To be signed upon arrival.) 

___________________________________________________________________________________________

Name of physician assistant (printed) 

_Jennifer Rocca-Sexton, PA-C

Signature 

___________________________________________

Date 

____________________________________________

 

National Provider Identifier 

_____1336131200________________________

Name of beneficiary (or his/her legal representative) 

____________________________________________    ___________________________________________

Signature 

____________________________________________

Date 

____________________________________________